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2015

Contextual and Cultural Influences on ParentalFeeding Practices and Involvement in Child CareCenters among Hispanic ParentsNoereem Z. Mena

Kathleen S. GormanUniversity of Rhode Island, kgorman@uri.edu

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Citation/Publisher AttributionMena, N. Z., Gorman, K., Dickin, K., Greene, G., & Tovar, A. (2015). Contextual and Cultural Influences on Parental FeedingPractices and Involvement in Child Care Centers among Hispanic Parents. Childhood Obesity, 11(4), 347-354. doi: 10.1089/chi.2014.0118Available at: http://dx.doi.org/10.1089/chi.2014.0118

AuthorsNoereem Z. Mena, Kathleen S. Gorman, Katie Dickin, Geoffrey Greene, and Alison Tovar

This article is available at DigitalCommons@URI: https://digitalcommons.uri.edu/nfs_facpubs/10

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Contextual and cultural influences on parental feeding practices and involvement in child-

care centers among Hispanic Parents

Noereem Z. Mena, MS, RD1* Kathleen Gorman, PhD,2 Kate Dickin3, Geoffrey Greene, PhD,1

Alison Tovar, PhD, MPH1

1 Department of Nutrition and Food Sciences, University of Rhode Island, Ranger Hall Kingston, Rhode Island, 02881, United States 2 Department of Psychology, University of Rhode Island, Chafee Hall, Kingston, Rhode Island, 02881, United States 3 Division of Nutritional Sciences, Cornell University, Savage Hall, Ithaca, New York, 14850, United States *Corresponding author: Email mnoereem@gmail.com Key Words: Feeding, Parents, Obesity, Children, Child-care, and Hispanic

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Background: Parental feeding practices shape children’s dietary preferences and behaviors,

which can influence a child’s weight status. Limited research exists on the precursors and

contextual influences of feeding, particularly among Hispanic parents. Therefore this study

explored two areas potentially important for obesity prevention in young children: 1) precursors

and contextual influences on parental feeding and 2) parental perceptions and knowledge of the

child-care food environment.

Methods: Four focus groups (n=36) were held with Hispanic parents, predominantly mothers, of

preschool children at two child-care centers. Parents were asked about influences on what and

how they feed their children, awareness of the child-care center feeding environment, and current

involvement in the child-care center. Themes were coded using NVivo10.

Results: Participants’ childhood experiences influenced how they feed their children. Parents

stated that both husbands and grandparents often indulged their children with unhealthy foods

and thought this interfered with their efforts to maintain a healthy home environment.

Participants reported that what their children ate while in child-care sometimes influenced the

home feeding environment.

Conclusion: Cultural and environmental factors influence parental feeding and involvement in

the child-care setting. Consistent with socio-ecological system theory, exploring interactions

between the environment and culture using a family-focus framework, such as the Family

Ecological Model (FEM) could provide a better understanding of these influences among

Hispanic parents. Future obesity prevention interventions with Hispanic families should be

culturally relevant and target the different environments where children spend their time.

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Introduction:

Obesity among preschool children (2-5 years) in the United States (US) has nearly tripled

over the last 30 years. 1 Although obesity rates appear to be decreasing among this age group,

ethnic disparities are evident whereby 17% of Hispanic children are obese compared to 3.5% of

their white non-Hispanic counterparts. 2 This is of concern, given that children who are

overweight by age 5 are more susceptible to obesity later in life 3 and that Hispanics are now the

fastest growing and largest minority population in the US. 4,5 Given that preschoolers are more

likely to change behaviors compared to older children,6 early obesity prevention among Hispanic

populations is critical.

Parents play a critical role in shaping children’s dietary preferences and eating

behaviors.7-13 Overall, evidence suggests that both parental feeding practices (i.e. restriction,

pressure to eat) and styles (i.e. authoritarian, indulgent) can negatively impact children’s eating

behavior and weight status.14-18 Although much of the literature has focused on white middle-

class families, some studies have found that feeding practices may vary by socio-economic status

(SES) and ethnicity.19-24 On one hand, restriction and pressure to eat has been found to be more

common among low-income Hispanic mothers when compared to low-income non-Hispanic

whites. 25 On the other hand, Hispanic parents are also more likely to engage in permissive and

indulgent feeding during meal times, compared to other racial and ethnic groups. 21-23,25-29

Although these practices have been associated with unhealthy dietary and weight outcomes,

there is limited evidence on what influences feeding practices,30,31 particularly among

Hispanics.19

In addition, the child feeding literature has focused primarily on parents and feeding

within the home, 31 but 60% of children in the US now spend some time in a child-care setting. 32

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This is important because growing evidence suggests that the child-care environment can

influence positive and negative dietary behaviors in young children. 33-37 Therefore, beginning to

explore how the child-care food environment might influence the home feeding environment is

of importance.

To help inform future obesity prevention efforts, cultural and environmental influences

on parental feeding and involvement in child-care settings need to be better understood. 38,39

Therefore the goals of this exploratory qualitative analysis were to explore: 1) precursors and

contextual factors that influence parental feeding and 2) parental perceptions and knowledge of

the child-care food environment. Given that there is limited research on this topic among

Hispanic parents, qualitative exploratory methods were needed. Focus groups (rather than

individual interviews) were selected as the most suitable approach to achieve the goal of

generating discussions that would reveal perceptions and beliefs

Methods:

The Rhode Island Department of Education provided a list of six child-care centers that

primarily served Hispanic families and participated in the United States Department of

Agriculture Child and Adult Care Food Program. This federal program provides reimbursement

for healthful meals and snacks served to low-income children and adults. 40 Although center

participation in this program is not a direct measure of income of the families they serve, it can

be used as a proxy indicator of socioeconomic status. All six centers were contacted. Four

directors responded and allowed parent recruitment to occur via flyers and during drop off and

pick up. A total of 60 participants were approached among the four centers over a four-week

period. "However, given the difficulty of recruiting at two centers (refusals and ineligibility),

they were dropped from the study. A total of 40 participants were recruited from the remaining

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two centers. Eligibility criteria for participants included: 18 years or older, a child between the

ages of 2-5, enrolled at the child care center, and self-identified as Hispanic/Latino ethnicity, and

Spanish or English speaking.

Out of 40 participants recruited at the two centers, 36 caregivers (34 mothers, 2

grandmothers) participated in one of four English or Spanish focus groups. Three participants

failed to attend and one was excluded from data analysis because they were not Hispanic/Latino.

Trained bilingual/bicultural moderators guided the focus groups and an assistant moderator took

notes, operated the digital recorder, and provided logistical support. The two focus groups

conducted in Spanish were moderated by A.T., while N.M. served as the assistant moderator.

N.M. moderated the English focus groups, while AT served as the assistant moderator. All focus

groups were conducted in the early evening (4.30-6 pm) and child-care was provided for the

children in a separate room. Standard protocol was used to conduct these focus groups. 41

Consent forms were reviewed and signed by the participants prior to the beginning of

each focus group. All focus group were digitally recorded and lasted approximately 60 minutes

and upon completion, participants completed a brief demographic survey. A $35 incentive to a

local super market was provided for participation. The study was reviewed and approved

Institutional Review Board at the University of Rhode Island, Kingston, Rhode Island.

Moderator Guide

The content of the moderator guide used to lead the focus group discussions was

informed by key informant interviews with directors, literature review, and discussions among

study investigators. After multiple revisions, the guide was pilot tested with six women

representing a similar demographic to our target population. Revisions were made to simplify

language and improve cultural appropriateness of the questions. The guide was then reviewed

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with other colleagues and additional revisions were made. The moderator guide focused on four

domains (Table 1). Domains were initially formulated to reflect the study aims and were revised

as needed throughout the development of the moderator guide.

Statistical Analysis

The two researchers (N.M. and A.T.) met after each focus group to discuss initial

findings and impressions. The Spanish audio recordings were translated and transcribed

verbatim, simultaneously by a trained bilingual research team member. The English audio

recordings were transcribed verbatim. NVivo (QSR) version 10 was used to assist in the

organization of qualitative data for further analysis. All transcripts were read and reviewed by

NM, who identified initial concepts and themes. 41 Structural coding was used to categorize the

data. Questions and key phrases from the moderator guide were used as structural codes. 42

Using the structural codes, the transcripts were systematically reviewed. Text segments were

then categorized into groups based on the moderator guide domains. Concepts and themes were

then reviewed multiple times to ensure that all of the a priori and emergent themes were

captured. Descriptive statistics were computed from the survey data, using SPSS version

22(IBM, Armonk, New York).

Results:

Of the 36 participating caregivers, 94% identified as mothers, and 31% identified as

Dominican (Table 2). Over half of the participants (55%) were non-US born but reported living

in the US for an average of 14.5 years. Seventy-two percent of the participants were over 26

years old. Less than half reported being married and approximately 55% of the participants had

at least some college education or a college degree or higher. The qualitative results are

7

presented according to the moderator guide domains. Themes are incorporated within each

domain.

Factors that influence what and how parents feed their children

Childhood experience

Participants’ childhood experiences influenced how they feed their children. Many of

them described that as children growing up, they weren’t allowed to waste food in their

household. Many shared stories about the “rule to finish your plate”, and in some cases, that even

meant that parents used physical force. The participants shared that the fear of “wasting food”

was somehow ingrained in them. In contrast, many commented that they had made a conscious

decision to use different feeding strategies with their own children:

“(My dad), he made us eat it and if we didn’t eat it, he would spank us. But I learned that

with my daughter I don’t have to be like that.”

This however could lead to feelings of guilt of wasting food:

“Sometimes I feel guilty because I don’t want to push her to do anything she doesn’t want

to…I say sometimes am I horrible that I’m not pushing her to eat her plate? Like oh my

God, I’m wasting food! You know?”

One mother expressed how she would end up eating the leftovers her children would leave on

their plates:

“I have to be honest because [although I don’t do this anymore], last year I was at the

point where my kids had to sit there and eat their food, because we were brought up that

wasting food was a very bad thing, when others didn’t have something to eat, you were

just throwing it away…But I noticed I would end up eating all the leftovers, and that

wasn’t doing me any good.”

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Family health concerns

Family health concerns, related to chronic disease, influenced what participants fed their

children. The most common health concern was diabetes. For example, some participants

mentioned not allowing sweets in the home environment or restricting how much and how often

the children could have sweets:

“The sugar and the diabetes, because my mom has diabetes so that’s kind of a concern in

my family, so I try to watch out what my kids are getting as far as sugary foods.”

and…

“…When people give me goodie bags I don’t see it because I’m almost throwing it out

the window…I just don’t want my children to be diabetic like me. I wasn’t born

diabetic… if I could prevent it now that’s what I want.”

Husband’s food preferences

Husband’s food preferences influenced what was served to the child in the home, and

often these preferences were reported to interfere with creating a more healthful food

environment for themselves and their children:

“My meals consist of rice, beans, and meat because that is what my husband likes to eat.”

In particular, mothers mentioned how their husband often modeled unhealthy behaviors, such as

drinking soda, in front of their children:

“My husband is a soda fanatic…it was a struggle because I wouldn’t let the girls drink it

and they would want it, but every time they would see him with a glass of soda, if he wasn’t

looking, they would run and try to grab a sip... it’s harder when everyone else around you is not

on the same page.”

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Time and work schedules

As expected, time and busy work schedules influenced parental feeding. The consensus

was that home-cooked meals required a lot of time, and there just wasn’t enough time in the day

to fit in cooking.

Grandparents

A recurrent theme throughout the focus groups was how culture and bi-generational

differences between the primary caregivers (mothers in majority of cases) and grandparents

influenced what their children ate. The mothers in all of the focus groups expressed their struggle

with their own parents when they fed their children non-traditional foods. One mother stated:

“When you take them to WIC, the nutritionist tells you what’s healthier… so I go by

[what she tells me]. My mom doesn’t think I should because she goes back to ‘oh she

needs rice and beans’”.

All of the mothers agreed that grandparent’s indulgent behaviors were an issue for them as it

contradicted their efforts to promote healthy eating habits for their children:

“When my son goes to visit my parent’s house, you’ve got the cookies, the juice, the

cereals, the chocolate milk, the Oreos, whatever he wants, he gets. There’s never a limit.

So that’s my struggle.

and…

“At los abuelos (grandparents)…it’s horrible. I would have to tell them to stop giving

him candy and junk food before meals...so basically we also have to be on top of other

people letting them know, to avoid all that.”

According to a few mothers, not indulging their grandchildren was taken very seriously by the

grandparents and was even called abusive because eating sweets should be part of being a child.

As one mother stated:

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“My family said that I was abusing her because I wouldn’t let her eat sweets. I wouldn’t

let her eat doughnuts… I wouldn’t let her drink soda. And they said that it wasn’t fair,

that every child should be able to have those kinds of things…”

Awareness of the child-care center feeding environment

Parents are aware of the child-care feeding environment influences in the home

Overall, the participants were aware of what foods were served at the center and thought

that the foods served were healthy. They reported that the child-care environment had both

positive and negative influences. Some reported that even though they did not purchase juice for

their household, as a result of seeing other children drinking juice at the center, their children

would ask for juice in the house and then would buy it:

“She started going to day care where there were older kids, and they drank juice. You

know she sees them, and she wants juice…and so then I buy juice.”

They voiced frustration over external influences and how this could lead to conflict

around food even though they try to encourage healthy behaviors at home:

“…And even if I teach her right and she sees another kid doing something, she’ll copy

that behavior. So like as far as sugar and juice, I don’t give her juice, but she’s seen one

person and that’s my fight right now.”

However, the child-care center also positively influenced what was eaten at home:

“At home when my son sees it (broccoli), he’s like ‘I want that’, and I’m like “You eat

that now?” And he’s like ‘Yeah they gave it to me at school’.”

It was evident that the participants were also aware that their children would eat certain foods at

the center and not in the home. They attributed this to peer influence. Many of the participants

agreed when one of them stated:

“I think my daughter eats better here (child-care center) because she sees other kids

eating. My daughter is an only child…I go home and I cook basically the same thing as

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here and she won’t eat it. But then I ask the teacher if she ate yesterday and she’s tell me

’Yeah! She ate well!’ So I guess it’s probably because she sees the other kids eating.”

They stated that having a child-care center with healthy practices would influence their

family choices and home environment. One participant responded: “…start doing it in the day

care, it will be easier for us to give them those foods without them saying ew! Or, no! I don’t

want it!” when asked how they felt about the center serving more healthful foods like fruits and

vegetables. Despite the positive aspects related to healthy changes at the center, some were not

as enthusiastic; similar to one study,43 some of our participants did say that “healthy foods” were

not “heavy” enough to sustain their children throughout the day. Some even believed that their

children would lose weight and be more susceptible to getting sick, as one participated stated:

“But the problem is they start eating those foods (more healthy foods) and get used to

that, they are going to lose weight. Imagine…they are going to get sick.”

Interestingly, a few participants were concerned that their children were not being adequately fed

during the day when at the child-care center. Some stated that portion sizes were too small

compared to portions served at home. The following captures some of these concerns:

“I think mine is still hungry after she eats breakfast here because she is used to eating

bigger portions at breakfast (at home).”

Despite their concerns over their children not being provided adequate amounts of food, many

agreed that they did not follow-up with the child-care staff to confirm what and how much their

children ate throughout the day. Many reported that although their children were most likely

unreliable, they relied on them to provide diet information throughout the day, as many stated: “I

usually ask him/her if she ate and what she ate.”

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Current involvement in the child-care center

Parents want to be more involved in child-care center nutrition initiatives

Participants expressed wanting to be actively involved in nutrition education programs at

the child-care center. However, time constraints and hectic schedules were the major factors in

preventing them from being more involved. As one participant expressed:

“Most of us, our kids are here because we are either working or in class, or we are doing

something. So if they have activities during the daytime, I can’t come. Sorry, you know? I

can’t miss a day of work, of class to come.”

Given their busy work and family schedules they acknowledged barriers to in-person

participation. They suggested the possibility of using email and text messages as alternatives as

many reported using these frequently. The majority of the responses included: “Email’s great!”

and “Yeah text messages…that’s easier for me.” Some even suggested weekend workshops to

attend with their children, a center blog where parents could view daily lesson plans, and tips on

how to reinforce the lessons on different fruits and vegetables introduced at the center within the

home.

Discussion:

The goals of our study were to explore precursors and contextual influences on parental

feeding and parental perceptions/knowledge of the child-care food environment. We found that

current feeding practices were influenced by past childhood experiences, cultural beliefs and

current family health concerns. Participants also stated that external influences such as their

children’s peer interactions within the child-care center influenced the home feeding

environment. Although participants described their awareness of healthy behaviors, they

expressed that their efforts to provide a healthful feeding environment were often undermined by

the grandparents’ indulgence or father’s preferences to eat unhealthy foods. Surprisingly,

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although many participants expressed concerns about diabetes, none of them mentioned obesity

as a health concern in their family. The participants reported wanting to be more involved in the

child-care center, however, as expected time constraints were the major barrier. These findings

highlight the complex nature of a child’s feeding environment and the need to intervene across

multiple levels of influence.

Similar to another study, we found that childhood memories influenced current feeding

practices with their own children. 44 Although this study did not assess current feeding practices,

participants reported use of less restrictive practices, such as allowing the child to decide when

they had enough to eat, which may promote internal cues of hunger and satiety, contrary to

outcomes associated with restrictive or controlling practices. 8 Some participants however

reported giving in to their children’s request for candy and juice, which is consistent with more

indulgent or permissive practices. These practices have not only been reported among Hispanics,

but are also positively associated with child body weight. 19,21-24,26

Mothers reported that their husbands’ food preferences and poor dietary habits made it

difficult for them to make positive dietary changes in the home. Although research with fathers

has been limited, this is consistent with prior work in that fathers are less likely to monitor food

intake and limit access to certain foods. 45 To our knowledge the literature has predominantly

focused on how maternal perceptions, knowledge, attitudes, beliefs, and diet influence child’s

health outcomes. 46-49 Based on our findings, more research is needed to explore how spouses

influence foods served and consumed in the home, which may affect the child’s dietary intake.

In addition to spouses, findings from our study also suggest that grandparents’ indulgent

behaviors were perceived as a barrier to healthful dietary changes in the home. This is consistent

with other studies in that parents and grandparents disagree about what foods their children

14

should be eating. 50-52 Grandparents appear to have just as much, if not more of an impact on

child’s dietary intake. 51 Although the grandparents’ indulgent behaviors may be associated with

culture, whereby the concept of familismo (emphasis of familial interconnectedness and loyalty

among family members), is prominent among Hispanics, 53 it is possible that intergenerational

differences such as grandparents’ childhood experience and cultural beliefs related to healthy

body size, exist. A study conducted among three-generation of Chinese families found that

grandparents influenced young children’s eating habits through the use of food to express their

love. 52 Their own experiences of poverty and cultural belief that obesity was a sign of health

influenced their view of a “healthy child”. 52 These findings suggest that grandparents’

influences on a child’s feeding environment are not just limited to Hispanics, but other racial and

ethnic families as well. However, it’s important to note that a grandparents’ occasional

indulgence shouldn’t be viewed as being only negative as grandparents’ involvement has been

associated with positive child outcomes. 50 However, many of the participants in our study

viewed it as a source of conflict suggesting an area to further investigate.

Given the central role that parents and families have in influencing a child’s health within

the Family Ecological Model (FEM), using this as a future theoretical framework could provide

a better understanding of the cultural and environmental influences among Hispanic parents. Our

findings support constructs within this model, 54 for example, parents’ childhood experiences and

intergenerational influences on feeding are highlighted as well as the importance of family

knowledge and social norms around food. Certain influences on child feeding, such as

grandparents, may be specific to the Hispanic culture however. A future study should test a

revised model adapted for Hispanic populations whereby the role of family is extended.

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Our findings are consistent with the prior literature in that a child’s peer social network

influences dietary behaviors.55 There is lack of evidence, however, on how a child’s different

environments are related or how environments influence interpersonal interactions such as child-

parent feeding. Future work may try to “bridge the gap” in continuity between the home and

child-care environment in an effort to move towards adopting an ecological perspective on a

child’s dietary intake. 33 It would be important to further explore how the child-care feeding

environment influences child’s diet quality in the home and vice-versa. As reported by Gubbels

et al., studies that assess the influences on children’s dietary behaviors and physical activity

levels focus on either the home or the child-care environment. 33 However, it is important to note

that both the home and child-care environments influence children’s behaviors related to weight

status. 56 Understanding that these two systems influence one another can help inform future

interventions where consistency across environments is key.

It is interesting to note that although healthy eating was discussed, obesity did not come

up as health concern for their families despite several prompts. This might suggest that our

participants are not concerned with obesity but rather focusing on an overall healthy lifestyle.

Also, some participants expressed fear that their kids could lose weight if they ate only healthy

foods. This suggests that parents are concerned with undernutrition rather than overnutrition in

their children, as parents not only in this study, but other studies as well, have expressed that a

“skinny” child may be perceived by others as a sign of poor health and inadequate parenting. 48,54

Perceptions on body weight may be influenced by acculturation, as one study found Mexican

mothers in the US preferred to have a thinner child, compared to Mexican mothers living in

Mexico. 57 Over half of the participants in our study were non-US born; it is possible that these

beliefs were associated with a less acculturated view on body weight which could in turn

16

influence how they feed their children. It is also possible that these families are food insecure

and are concerned about their children getting enough food.

Our study also reveals that parents want to be involved in nutrition programs in the child-

care center but time and work schedules, as expected, were posed as major barriers. Given their

enthusiasm to suggest alternative ways to be involved without in-person participation, further

research should focus on more innovative ways to involve parents within the child-care setting,

such as using blogs or other technology mediums like emails and text messages.

Nonetheless, our study is not without limitations. Although our study was meant to be

inclusive of all parents and caregivers among this population, our participants were

predominately women. In addition, we were only able to successfully recruit from two of the

four centers; it is possible that parents from these centers are more involved and health conscious

than those who are harder to reach. Gender roles are shifting, but mothers in this population

continue to be primary caregiver and in charge of food preparation in the home. 58,59 Our sample

size was limited, and the majority of the women in our study who reported their ethnicity,

identified as Dominican, thus findings may not be generalizable to other Hispanic or Latino

subgroups. There is also the risk of self-selection bias at the center level and the possibility of a

reduced diversity of views expressed due to the use of focus group discussions. 54

Conclusion

Cultural and environmental factors influence parental feeding and involvement in the

child-care setting. Future work should apply the FEM54 and adapt for use with Hispanic families

in order to further understand different levels of these influences on parental feeding and

involvement. Future obesity prevention interventions with Hispanic parents of young children

should be culturally relevant and target different environments which children spend time in.

17

Acknowledgements

This project was supported, in part, by the USDA National Institute of Food and Agriculture,

Hatch capacity grants, project #RI00H-90, administered by the Rhode Island Agricultural

Experiment Station.

Author Disclosure Statement

No competing financial interests exist.

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